Reasoning GP · Algorithm · 1-page summary
Tremor in adults
For: adults with new or changing tremor in primary care. Not for: children (use paediatric pathways). Long-term care of confirmed essential tremor → essential tremor protocol; Parkinson's treatment is neurology-led.
Core rule: rest vs action is the key question — asymmetric rest tremor with bradykinesia suggests Parkinson's (refer); bilateral action tremor with an otherwise normal examination suggests essential tremor. Always exclude thyrotoxicosis and a tremorgenic drug first.
0Stop — call 999 now — tremor with altered consciousness, toxicity or focal signs
- Delirium tremens: tremor + confusion + fever, 6–72 h after stopping alcohol; high seizure risk → 999 hospital admission.
- Serotonin syndrome: tremor + agitation + clonus/hyperreflexia after a serotonergic drug change → stop ALL serotonergic drugs → 999. NMS: lead-pipe rigidity + hyperthermia + autonomic instability on antipsychotics → stop antipsychotics → 999
- Thyroid storm (fever + confusion + arrhythmia) → 999 emergency admission; not propranolol alone. Sudden tremor + confusion + acute headache + focal deficit (bleed, tumour, abscess) → 999 / stroke pathway.
- While waiting: treatment is hospital-led (benzodiazepine and thiamine for DTs per hospital protocol; cyproheptadine, bromocriptine, dantrolene specialist only).
1Triage — when does the tremor occur?
| Tremor | Points to → action |
|---|---|
| At rest | Pill-rolling, unilateral onset + bradykinesia → parkinsonism → Urgent neurology |
| Posture + action | Bilateral, normal examination → essential tremor |
| Intention | Worse near target → cerebellar → Urgent neurology |
| Fine, fast | Clear trigger → physiological / drug. Variable, distractible → functional |
2Screen — one row is enough
- Lithium + worsening tremor → timed level, U&E/eGFR, sodium Same-day. >1.5 mmol/L → withhold, urgent advice; toxicity signs → emergency assessment.
- Thyrotoxicosis: tachycardia, heat intolerance, weight loss → Urgent TFTs.
- Wilson's: under 40 + psychiatric change, liver disease, dystonia or family history → Urgent neurology/hepatology; acute liver failure → 999 / Same-day
- Suspected Parkinson's (rest tremor + bradykinesia) → Urgent neurology; do not wait for imaging.
- Abnormal neurology, markedly asymmetric, rapidly progressive or atypical → Urgent neurology (NG127).
- Metoclopramide: stop; acute dystonia, oculogyric crisis, laryngospasm → Same-day acute.
3Assess — once blocks 0–2 are answered
☐ Hands on lap ☐ arms out 30 s (ET at once; PD re-emerges after 5–15 s) ☐ finger-nose ☐ bradykinesia, rigidity, gait, eyes, speech, focal signs ☐ spiral, handwriting ☐ drugs, caffeine, alcohol
☐ Targeted: TSH + free T4 if thyroid possible; glucose/HbA1c; U&E/eGFR, LFTs; lithium/valproate level if relevant. Not routine: CK, copper in every young person, NCS/EMG; MRI for typical longstanding bilateral action tremor with normal examination.
4Classify — only if the screen is negative
- Essential tremor — bilateral upper-limb action tremor ± head/voice; family history supportive; no other signs → reassure if mild, treat if disabling.
- Parkinson's — rest tremor + bradykinesia (isolated tremor is not Parkinson's) → refer quickly.
- Cerebellar — intention tremor + ataxia, nystagmus, dysarthria → urgent neurology.
- Physiological / drug — anxiety, caffeine, β-agonists, lithium, valproate, SSRIs, withdrawal → remove the cause.
- Functional — variability, entrainment, distractibility → positive explanation; neurology / FND therapy.
- Uncertain — say so → neurology; reassess if features evolve.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Disabling ET: propranolol may be considered — check contraindications (asthma/obstructive airways, bradycardia, heart block, hypotension, heart failure, PVD/Raynaud's, diabetes); start low, titrate by pulse, BP. Second line primidone: very low at night, slowly; check falls, driving, interactions, pregnancy. Topiramate/gabapentin specialist only.
- Performance anxiety: propranolol 40 mg once, 30–60 min before; not for ET; no unreviewed repeats.
- Drug-induced: valproate changes only with neurology/psychiatry (MHRA reproductive safety, incl. men); SSRI → review or switch.
- All: less caffeine, nicotine, stimulants; manage anxiety; never alcohol as treatment; OT, weighted utensils.
6Refer routinely
- ET refractory to propranolol and/or primidone → Routine neurology (DBS or focused ultrasound if severe).
- Thyrotoxicosis as the driver → endocrinology. Awaiting Parkinson's diagnosis → falls assessment; disabling wait → specialist advice.
7Never reassure by
- Improvement with alcohol — not diagnostic of ET, and a dependence risk.
- Tremor frequency, or waiting for imaging before referring suspected Parkinson's.
- Labelling a young adult "anxious" — consider Wilson's and functional tremor.
- Waiting for routine monitoring when tremor worsens on lithium.
- Calling tremor without bradykinesia Parkinson's, or starting levodopa yourself.
8Safety-net — say it, then document it
999 “Call 999 if the tremor comes with confusion, fever, stiffness, sweating, a sudden severe headache or new weakness.” Same week “Contact us if the tremor gets much worse on a new medicine, or Parkinson's symptoms worsen quickly.”
Follow-up: propranolol/primidone review at 6 weeks, 3-monthly at target dose, then yearly. Driving: advise checking DVLA standards and notifying where required (e.g. Parkinson's; ET only if it affects control); document.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Rest / posture / intention and full neurological examination recorded
Thyroid, drug, caffeine and alcohol causes checked
One diagnosis explains it, or uncertainty → neurology
Review date, DVLA advice and safety-net documented
Summary of the full Reasoning GP tremor algorithm, which holds the detail, examination and evidence. Sources: NICE NG71, NG127, HTG474; MHRA valproate and topiramate safety; SPS monitoring; EFNS/MDS essential tremor; EASL Wilson's; DVLA. Clinical reference — follow local policies and check doses: NICE/SPC, BNF.